Healthcare Provider Details

I. General information

NPI: 1487478186
Provider Name (Legal Business Name): HEATHER ELIZABETH DARK PHD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N WOLFE ST
BALTIMORE MD
21205-2110
US

IV. Provider business mailing address

525 N WOLFE ST
BALTIMORE MD
21205-2110
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-4766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number07350
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008719
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: